A preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional or patient/consumer.
- Also known as a medication incident.
- Errors can happen in any health care setting.
Medication incidents can have a devastating impact on:
- the individual affected and their family.
- the health care providers.
What is a Near Miss?
An event that could have resulted in unwanted consequences but did not because either by chance or through timely intervention the event did not reach the patient. Also known as a good catch.
Examples of Medication Errors include:
- A failure to inquire whether a patient has a known allergy to medication, or administration of a medication where a patient’s allergy had been identified.
- Wrong-route administration of chemotherapy agents, such as vincristine administered intrathecally (injected into the spinal canal).
- Intravenous administration of a concentrated potassium solution.
- Inadvertent injection of epinephrine intended for topical use.
- Overdose of hydromorphone by administration of a higher concentration solution than intended (e.g., 10 times the dosage by drawing from a 10 mg/mL solution instead of a 1 mg/mL solution, or not accounting for needed dilution/dosage adjustment).
- Neuromuscular blockade without sedation, airway control and ventilation capability.
- Mishandling of High-Alert Medications as they can result in significant patient harm when they are used in error.
Solution: harvesting a safety culture in a no-blame one!
A safety culture recognizes that:
- Humans are incapable of perfect performance and errors are expected.
- Errors are caused by flaws in the working environment (system).
- Focuses on improving the processes, systems, and environment in which people work.
- Shifting from a Person-based approach to a System-based approach is the key to developing useful strategies that can be easily adapted by an organization to prevent such errors:
- Understanding WHY an error occurred and the contributing factors is key to the success of an error analysis.
- Consider human factors and system factors during analysis and when developing strategies.
- Strategies to prevernt these errors should be based on the contributing factors identified.
Reporting near misses and medication errors makes a difference! The more detail about the incident that is included, the more helpful it is for analysis purposes. By sharing your learning, you can save a life.
“People working in health care are among the most educated and dedicated workforce in any industry. The problem is not bad people; the problem is that the system needs to be made safer.”
To Err is Human: Building a Safer Health System, IOM Report 1999.
- Over-utilization of Proton-Pump Inhibitors
- Compounding Pharmacy Violations Which Put Patients at Risk
Resource Person: Lobna Adi